Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Retreat, The during CMS and state inspections, most recent first.
Improper Storage of Nebulizer Mask and Tubing: A resident receiving scheduled nebulizer treatments and O2 had the nebulizer facemask and tubing observed lying on a dresser and on top of a ziplock bag open to air rather than stored in the bag. An LPN confirmed the mask was not bagged, and the ADON and DON stated the respiratory equipment should be stored in a ziplock bag.
The facility failed to discard expired food items, including tomato slices, lemonade, tea, bread, and evaporated milk, as observed during a kitchen tour. The ADM acknowledged responsibility, citing task management challenges, while the DM confirmed the policy of discarding food on expiration dates. This oversight potentially risked 46 residents to foodborne illness.
A facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate. Three residents received incorrect medications or dosages due to errors by an RN. The errors were confirmed by the RN and verified by the DON. The facility's policy requires medication verification with the eMAR to ensure correct administration.
Expired medications were found in the facility's medication storage room, including naproxen and vitamin B1, with expiration dates of January and February 2025, respectively. The DON confirmed the presence of these expired medications, and interviews revealed that both the pharmacist and nurses were responsible for ensuring no expired medications were stocked, as per facility policy.
A facility failed to follow infection control procedures during wound care for a resident with a stage 3 pressure ulcer. Staff did not perform hand hygiene between glove changes and did not wear gowns as required by Enhanced Barrier Precautions (EBP). Interviews confirmed the failure to adhere to EBP and hand hygiene protocols, despite staff education and availability of PPE.
Improper Storage of Nebulizer Mask and Tubing
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not use appropriate infection control practices during respiratory therapy for one resident. The resident, R41, was admitted with diagnoses including moderate intellectual disabilities, mild intermittent asthma with acute exacerbation, dysphagia, and pulmonary issues, and the MDS indicated a BIMS score of 13, showing the resident was cognitively intact. R41’s care plan included scheduled nebulizers for an acute asthma exacerbation, and physician orders included ipratropium-albuterol nebulization four times daily and oxygen at 2 LPM via nasal cannula every 8 hours. During observations, R41’s nebulizer facemask and tubing were found stored improperly. On one observation, the nebulizer was at bedside with tubing lying on top of a ziplock bag, and later the mask remained sitting on top of the ziplock bag open to air while the resident was out of the room. On another observation, the nebulizer mask was lying on the dresser beside the ziplock bag, and an LPN confirmed it was on the dresser and not bagged. The ADON stated the nurse probably placed the mask on the plastic bag to allow it to dry and confirmed that laying on the plastic bag was not appropriate, while the Administrator stated the respiratory tubing and mask should be stored in a ziplock bag.
Expired Food Items Not Discarded
Penalty
Summary
The facility failed to ensure that expired food items were discarded in accordance with their policy and the 2017 Federal Food Code, which could potentially place 46 residents at risk of contracting a foodborne illness. During a kitchen tour, surveyors observed expired food items in the refrigerator, including a metal serving container labeled Tomato Slice, eight one-gallon containers of Lemonade, and six one-gallon containers of Tea, all past their expiration dates. Additionally, expired loaves of sandwich white bread and cans of evaporated milk were found in the bread storage racks and dry storage pantry, respectively. These findings were confirmed by the Assistant Dietary Manager (ADM). The ADM admitted responsibility for not discarding the expired foods, citing her focus on serving food and managing multiple tasks as reasons for the oversight. She stated that she, along with the Dietary Manager (DM) and a Dietary Aide, were responsible for checking food dates. The DM confirmed that food items should be discarded on their expiration date, indicating a lapse in adherence to the facility's food storage policy and procedures.
Medication Administration Errors Lead to 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 10 percent error rate during the observed period. This was identified through observations, staff interviews, and record reviews. The errors involved three residents, each receiving incorrect medications or dosages. Resident 13, diagnosed with hypokalemia and gastro-esophageal reflux disease, was supposed to receive vitamin D3 125 mcg (5000 IU) but was instead given calcium 60 mg, 10 mcg (400 IU). Resident 49, with anorexia and anemia in chronic kidney disease, was ordered sodium bicarbonate 325 mg, two tablets, but received only one tablet. Resident 6, diagnosed with vitamin D deficiency, was ordered vitamin D3 25 mcg (1000 IU) but was administered calcium 600 mg, 10 mcg (400 IU). The errors were confirmed by RN CC, who acknowledged administering the incorrect medications and dosages to the residents. The Director of Nursing verified these errors upon review. The Assistant Director of Nursing stated that nurses are expected to verify medications with the electronic medication administration record (eMAR) to ensure the correct medication and dosage are administered to the right resident at the right time. The facility's policy on medication administration, revised in June 2023, requires that medications be administered only upon the order of authorized medical staff and that the medication administration record be compared with the patient's medical record prior to preparation.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that no expired medications were stored in the medication storage room, which could potentially place residents at risk of receiving medications with altered effectiveness. During an observation conducted with the Director of Nurses (DON), it was found that a container of naproxen 220 mg with an expiration date of January 2025 and a container of vitamin B1 100 mg with an expiration date of February 2025 were present in the medication storage room. The DON confirmed the presence of these expired medications. Interviews with the DON and the Administrator revealed that the pharmacy was responsible for stocking the medication storage room, and both the pharmacist and nurses were expected to review the medications to ensure no expired medications were present. The facility's policies on Floor Stock and Medication Administration emphasized the importance of checking expiration dates before administration, yet this practice was not adhered to, leading to the storage of expired medications.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure effective infection control procedures during wound care for a resident with a stage 3 pressure ulcer. The facility's policies on Hand Hygiene and Enhanced Barrier Precautions (EBP) were not followed. During an observation of wound care, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes, and neither wore a gown as required by the EBP policy. The RN prepared supplies and removed dirty wound dressings without sanitizing hands between glove changes, which is against the facility's hand hygiene policy. Interviews with staff, including the RN, Assistant Director of Nursing (ADON), Infection Control Coordinator, and Director of Nursing (DON), confirmed the failure to adhere to the EBP and hand hygiene protocols. The RN acknowledged not performing hand hygiene between glove changes and not wearing a gown during the procedure. The ADON and Infection Control Coordinator stated that EBP should be followed during wound care to prevent infection spread, and the DON confirmed that PPE was available and staff had been educated on EBP requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westbury Center Of Jackson For Nursing And Healing | 16.7 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Monroe | 19.1 mi | ★★★★★ | 0 | 0 |
| Eatonton Health And Rehabilitation | 19.7 mi | ★★★★★ | 0 | 0 |
| Lynn Haven Health And Rehabilitation | 19.7 mi | ★★★★★ | 4 | 0 |
| Madison Health And Rehab | 22.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.